ARKANSAS STATE BOARD OF ATHLETIC TRAINING
9 SHACKLEFORD PLAZA, SUITE 3
LITTLE ROCK, AR 72211
Application Instructions for Athletic Trainer
Licensure/Temporary Permit
• Education:
Athletic trainers seeking licensure in the state of Arkansas must possess a baccalaureate degree from an accredited
institution.
• All Applications for Licensure and One Year Non-Renewable Temporary Permits:
1. Licensure and Temporary Permit Applicants: (You must answer all questions on the application or it will be
returned for completion). A passport type photograph taken within one year must be attached and embossed with
an official Notary seal or stamp. Attach your photograph to the application before having it notarized. Part of the
notary seal or stamp should be on the picture and part should be on the application form.
2. Facsimile copies of the application and all other application forms are not acceptable.
• Required Documents:
1. Initial Licensure by Examination/Certification Applicants:
a. The Board will verify your NATABOC certification on the NATABOC website.
b. The Physician Direction Form should be submitted to the Arkansas State Board of Athletic Training if you
are partially or fully practicing in a non-clinical setting.
2. Initial Licensure by Examination/Certification for full time graduate students already NATABOC
Certified:
a. The Board will verify your NATABOC certification on the NATABOC website.
b. The Physician Direction Form should be submitted to the Arkansas State Board of Athletic Training if you
are partially or fully practicing in a non-clinical setting.
c. Please provide a letter from a responsible party at the College or University you attend that indicates that you
have full time graduate student status.
3. Initial Licensure by Reciprocity Applicants:
a. The Board will verify your NATABOC certification on the NATABOC website.
b. The Physician Direction Form should be submitted to the Arkansas State Board of Athletic Training if you
are partially or fully practicing in a non-clinical setting.
c. The Reciprocity Verification Form should be submitted to all states in which you are currently credentialed as
an athletic trainer. This form should be sent back directly to the Arkansas State Board of Athletic Training by
the appropriate state agencies.
4. Temporary Permit Application
a. The NATABOC Certification Examination Eligibility Form will only be accepted if sent back directly to the
Arkansas State Board of Athletic Training by the NATABOC.
b. The Physician Direction Form should be submitted to the Arkansas State Board of Athletic Training.
Fees:
Licensure by Examination/Certification Application Fee:
Licensure by Examination/Certification Initial Licensure Fee:
$25.00
$100.00
Total fee to mail with exam/certification application:
$125.00
Licensure by Examination/Certification for full time graduate students
already NATABOC Certified Application Fee:
Licensure by Examination/Certification for full time graduate students
already NATABOC Certified Initial Licensure Fee:
$25.00
$50.00
Total fee to mail with application:
$75.00
Licensure by Reciprocity Application Fee:
Licensure by Reciprocity Initial Licensure Fee:
$25.00
$100.00
Total fee to mail with reciprocity application:
$125.00
Temporary Permit Application Fee:
Temporary Permit Licensure Fee:
$25.00
$300.00 * quarterly
Total fee to mail with application:
$325.00 **
*This fee is a total of $1200.00 annually, but can be paid on a quarterly basis. **The application fee is due only
once with the first temporary permit application. A reminder of quarterly payment due will not be sent to the
person holding a temporary permit. Unpaid quarterly permits become inactive on the 10th day after the
quarterly payment fee deadline.
License Renewals:
Licenses are effective from July 1 to June 30th of the following year. Renewal fees are due upon receipt of the
renewal notice. Those graduate students already NATABOC certified must provide a letter from a responsible
party at the University where they have full time graduate student status indicating their full time student status.
Unrenewed licenses become inactive as of July 1. To return to regular status, a reactivation fee must be paid in
addition to the renewal fee. Licenses reactivated after September 30th will be assessed a late fee in addition to
the renewal fee and the reactivation fee.
Renewal Fee:
Renewal Fee:
Reactivation Fee:
Late Fee:
$50.00
$25.00 for graduate student already NATABOC certified
$75.00
$100.00
ARKANSAS STATE BOARD OF ATHLETIC TRAINING
9 Shackleford Plaza, Suite 3
Little Rock, AR 72211
(501) 683-4076
APPLICATION FOR LICENSURE OF ATHLETIC TRAINERS
Please print or type answers to all questions
Please check the appropriate box:
r Initial License by Examination/Certification
r Reciprocity r Temporary Permit
BOC Certification # _____________________ National Provider Identifier (NPI) # _____________________
General Information
Last Name_______________________First_____________Middle_______________Maiden______________
Address____________________________________________________________________________
City ________________________________ State _________Zip__________ County ___________________
Home Phone _________________________________ Work Phone __________________________________
Fax _________________________________ Email ______________________________________________
Social Security # _________________ City & State of Birth ____________________ Date of Birth ________
Gender: r Male
r Female
Ethnic/Race Information: o American Indian or Alaska Native
o Asian
o Black or African American
o Hispanic/Latino
o Native Hawaiian or Other Pacific Islander
o White/Caucasian
EDUCATION:
State in chronological order the name and location of each college or university attended.
Name/Location of School
Dates Attended
Major
Degree
_________________________________________________________________________________________
_________________________________________________________________________________________
ADDITIONAL INFORMATION: (attach additional sheet if necessary.)
Are you credentialed as an AT in any other state? ____ If yes, please list each state. _____________________
Verification of credentials must be sent directly from each state agency
Have you previously been denied AT credentials by any governing agency or the NATABOC? _____________
If yes, please explain. _______________________________________________________________________
Have your AT credentials ever been revoked by any governing or state agency?_____
If yes, please explain.
_________________________________________________________________________________________
Have you ever been convicted of a crime? ______ If yes, please explain.
_________________________________________________________________________________________
_________________________________________________________________________________________
ATHLETIC TRAINING EXPERIENCE
Dates
Employer/Location
Supervisor/Address____________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
PHOTOGRAPH
(Affix photo here.)
A passport type photograph taken within one
year must be attached and embossed with an
official notary seal or stamp. Attach your
photo to the application form before it is
notarized. Part of the notary seal or stamp
should be on the photo and part on the
application form.
NOTARIZED - This is to certify that the photograph attached is a correct likeness of the applicant.
___________________________________Notary Public My commission expires ____________________
Appropriate fees must accompany application. See instruction sheets for fee schedule. Your notarized
signature must accompany this application.
I, ______________________________ hereby certify under oath or affirmation that I am the person named in
the application. I swear/affirm that the contents of this application are true. All information contained in this
application may be verified by the Arkansas State Board of Athletic Training.
_____________________________________________________________
APPLICANT'S SIGNATURE
Sworn to before me this____________ day of ______________, 20_______
_____________________________________________________________
NOTARY PUBLIC
Arkansas State Board of Athletic Training
9 Shackleford Plaza, Suite 3 * Little Rock, AR 72211 * 501-683-4076
ATHLETIC TRAINER LICENSE/TEMPORARY PERMIT
PHYSICIAN DIRECTION FORM
Athletic Trainer Name: _________________________NPI Number: ___________________________
Address: ___________________________________ City/State/Zip: ____________________________
Home Phone: ______________________________ Work Phone: ______________________________
Directions to Applicant: If practicing fully or partially in a non-clinical setting, please request your
supervising/directing physician to complete the following form and return to the address listed above.
Ark. Code Ann S 17-93-411 of 1995 Act 1279 licenses athletic trainers and requires the following supervision
of the athletic trainer.
1. In a non-clinical traditional setting, the athletic trainer may practice the art and science of athletic
training under the direction of a physician licensed in the state of Arkansas.
2. In a clinical setting, the athletic trainer may practice athletic training in a hospital or outpatient clinic
under the direct supervision of a physical therapist and upon the referral of a physician licensed in the
state of Arkansas.
Directions to Physician: Please read the information below and complete the following.
Supervising / Directing Physician: a person holding a current unrestricted license to engage in the practice of
medicine or osteopathy. Other physicians, who act on a referral basis with athletic trainers will hold a current
unrestricted license to engage in the practice of chiropractic, optometry, and podiatry in the state of Arkansas.
Please check the activity or activities for which direction is given:
r 1. Interscholastic (High School Athletics)
r 2. Intramural
r 3. Intercollegiate (College Athletics)
r 4. Professional
r 5. Sanctioned Recreational Sports Activities:
r a. Has officially designated coaches who have the responsibility for athletic
activities of the organization.
r b. Has a regular schedule of practices or workouts which are supervised by the
officially designated coaches.
r c. Is an activity generally recognized as having an established schedule of
competitive events of exhibitions.
r d. Has a policy requiring documentation of having passed a pre-participation
medical examination conducted by a licensed physician as a condition for participation in the
athletic activities of the organization.
___________________________________________________________________________________
Physician's Name (please print)
Date
Physician's Signature
Physician's Address __________________________________________________________________
City/State/Zip__________________________________ Phone Number ________________________
Arkansas State Board of Athletic Training
Athletic Trainer Temporary Permit
Board of Certification (BOC)
Certification Examination Eligibility Form
Directions to Applicant:
The applicant must have taken the BOC Certification Exam or be eligible for the exam. Requests for application
for the BOC Certification Exam must be submitted with the required materials to:
Board of Certification, Inc.
1415 Harney Street, Suite 200
Omaha, Nebraska 68102
Name: _____________________________________ Social Security Number: ___________________
Address: ___________________________________ City/State/Zip: ____________________________
Home Phone: ______________________________ Work Phone: ______________________________
Directions to the NATABOC:
The applicant is applying for an Arkansas Temporary One-Year Nonrenewable Athletic Trainer Permit.
Please review the applicant's eligibility for the BOC Certification exam.
Please complete the following and return directly to:
Arkansas State Board of Athletic Training
9 Shackleford Plaza, Suite 3
Little Rock, AR 72211
(501) 683-4076
Please check:
r Is eligible for the BOC Certification Examination
r Is not eligible for the BOC Certification Examination
Seal
________________________________
Signature (NATABOC official)
Title ___________________________
Date ___________________________
Arkansas State Board of Athletic Training
9 Shackleford Plaza, Suite 3
Little Rock, AR 72211
RECIPROCITY VERIFICATION FORM
Applicant: Complete top section and send entire page to the state licensing board/s where all AT credentials
have been granted. Please make additional copies and send to all states where AT credentials were granted. The
Board must determine whether the credentials you hold as an AT are at least equal in requirements to Arkansas'
requirements.
Date: _______________________
Name: _______________________________________________________________________
Last
First
Middle
Maiden
Address: _________________________________________ ___________________________
Street
Home Phone
_________________________________________ ___________________________
City
State
Zip
Work Phone
__________________________ __________________________________________
Social Security #
State of Licensure/Certification/Registration
The following section is to be completed by state licensing board where license / certificate
/registration was obtained.
The Board of _________________________of the State of ___________________hereby
certifies that ___________________________________________________was issued
license/certificate/registration number ________________ on _______________________
The license/certificate/registration expires on ______________________.
Disciplinary action: _______ Yes _______ No
NOTE:
If disciplinary action has been taken against this individual, please provide additional
information.
(SEAL)
___________________________________
Signature of Authorized Representative
Return directly to the address indicated above.
____________
Date